ASSESSMENT REQUEST FORM

Use this form to request a free assessment for students 3 years and up or students of any age who have special needs. Assessments are offered in San Jose on Tuesdays, Fridays & Saturdays with time options noted below.

This is a completely non threatening - in fact quite fun - time when we learn about your student's learning style, aptitudes, strengths, etc. Then we take some time to talk with you about the very best learning options for your child.

Student Name *

First Name Last Name

Date of Birth *

Gender

Male Female Unspecified

Any Special Needs? *

Yes No Unsure

Please explain special needs or diagnosis: *

Have you been enrolled before? *

NO, our family is new to the Music Place YES, our family has been enrolled previously

Voucher or Coupon Code?

Available w/ some special offers

Primary Parent Contact *

First Name Last Name

Additional Adult Contact

First Name Last Name

Zip Code *

Address or Nearest Cross Streets

Help us find best location...

Best Phone Number *

Whose phone number is this? *

Home Dad's Cell Mom's Cell Dad's Work Mom's Work Other

I understand that I may receive occasional text messages to schedule or confirm my assessment or other services.

I agree to receive text messages at the number(s) supplied.

Best Contact Email *

example@example.com

Reason(s) for Assessment? *

Child under 7 interested in instrumental lessons Need First steps placement advice One of my children has special needs Re-assessment check in Need 2nd instrument placement advice My teacher suggested this other

ASSESSMENT REQUEST FORM

Student Information

Parent Contact Information

SCHEDULING YOUR ASSESSMENT

THANK YOU FOR YOUR REQUEST!